Anesthesia for pediatric endoscopy

We are in agreement with the policy recently emphasized by the N e w England Journal of Medicine. s When a manuscript is submitted, or at any time in the prepublication period, we ask t h a t authors send, for our comparison, copies of any related manuscripts t h a t are in press or under consideration elsewhere. Related published articles should always be referenced. This open approach should avoid misunderstandings, and settle concerns about redundant publication. A final recent change in our "Instructions to Authors" involves Letters to the Editor. Letters can be fun to read and can highlight colorful controversial issues, but we may have had too m a n y case reports in this section. I believe that Letters to the Editor should primarily comment on articles published in the journal, forming a section of open peer review or uninvited editorials. Designated editorials in the journal are always invited, and are generally written by experts who usually served as reviewers for articles published in that issue. The views expressed are not necessarily my own or those of the ASGE, but ones I considered worthy, or necessary for balance. Letters should be prepared in the form of a manuscript as directed in the "Instructions" and not like a business letter, since they will be edited for publication. Space limitations do not allow publication of all the Letters I receive, but I would like to receive more t h a t comment on our published articles. I take these Letters very seriously. Letters may be humorous or contentious, but personal attacks (on the Editor or anyone else) will not be accepted.

Charles J. Lightdale, MD New York, New York

REFERENCES 1. Huth EJ. Structured abstracts for papers reporting clinical triMs (Editorial). Ann Intern Med 1987;106:626-7. 2. Relman AS. New "information for authors" and readers (Editorial). N. Engl J Med 1990;323:56. 3. Witt MD, Gostin LO. Conflict of interest dilemmas in biomedical research. JAMA 1994;271:547-51. 4. Rothman KJ. Conflict of interest. The new McCarthyism in science. JAMA 1993;269:2782-4. 5. Koshland DE. Simplicity and complexity in conflict ofintorest (Editorial). Science 1993;261:11. 6. International Committee of Medical Journal Editors. Conflict of interest (Editorial). Ann Intern Med 1993;118:646-7. 7. Hammerschmidt DE. Echoes in the halls: thoughts on double publication (Editorial). J Lab Clin Med 1992;119:109-10. 8. Kassirer JP, Angell M. Redundant publication: a reminder (Editorial). N Engl J Med 1995;333:449-50.

Letters to the Editor Anesthesia for pediatric endoscopy To the Editor: The best method of sedation for endoscopy in children rem a i n s a n a r e a of h e a t e d controversy in the pediatric gas596

GASTROINTESTINAL ENDOSCOPY

trointestinal community. 14 Some pediatric gastroenterologists suggest t h a t all sedation belongs in t h e h a n d s of the anesthesiologist, 1 whereas others claim no sedation is needed at all. 5, 6 Fortunately, the beliefs of most practicing pediatric gastroenterologists fall comfortably between such extremes. Both general a n e s t h e s i a and intravenous sedation have t h e i r respective indications in pediatric endoscopy, with the balance clearly leaning toward intravenous sedation. Squires et al. 4 have a t t e m p t e d to d e m o n s t r a t e the safety and efficacy of intravenous sedation a n d point out the significant cost differential versus general anesthesia. They created a n innovative "Relative Adequacy Scale" to grade the activity a n d cooperation of children u n d e r intravenous sedation. Although an imperfect i n s t r u m e n t , such a scale ill u s t r a t e s the quality of sedation commonly achieved in children using intravenous sedation a n d also points out the occasional (8% of patients) need for r e s t r a i n t during endoscopy. Overall, t h e y found t h a t 95% of procedures were successfully completed using intravenous sedation, typically midazolam a n d meperidine. No differences were found comparing the safety of general a n e s t h e s i a versus t h a t of intravenous sedation. The duration of endoscopic procedures in children was eye opening. Most a d u l t gastroenterologists would be a g h a s t to see how long it can t a k e to safely and efficiently perform endoscopy in children. Although the duration seems excessive, it is certainly more the norm in children, where proper patient p r e p a r a t i o n a n d careful titering of the intravenous sedation does indeed t a k e time. The actual time to do the "endoscopy" is likely not too different from t h a t in adults. A per procedure cost differential of $1196.90 between general a n e s t h e s i a and intravenous sedation is impressive a n d real. Such a cost difference cannot be ignored. If indeed the safety a n d efficacy are similar between general anest h e s i a and intravenous sedation, it clearly a r g u e s t o w a r d the performance of endoscopy in children using intravenous sedation. The study of such routine clinical practice, in this case pediatric endoscopy, is not glamorous. It is, however, valuable a n d practical, a n d more research is needed in children. Squires et al. 4 are to be commended for t h e i r efforts.

Mark A. Gilger, MD Bay~or Co//ege of Medicine Houston, Texas

REFERENCES 1. Hassall E. Should pediatric gastroenterologists be I.V. drug users? J Pediatr Gastroenterol Nutr 1993;39:387-92. 2. Ament ME, Brill JE. Pediatric endoscopy, deep sedation, conscious sedation and general anesthesia--what is best? Gastrointest Endosc 1995;41:173-5. 3. Gilger MA. Conscious sedation for endoscopy in the pediatric patient. Gastrointestinal Nursing 1993;16:75-9. 4. Squires RH, Morriss F, Schluterman S, Drews B, Galyen L, Brown K. Efficacy, safety and cost of intravenous sedation versus general anesthesia in children undergoing endoscopic procedures. Gastrointest Endosc 1995;41:99-104. 5. Hargrove CB, Ulshen MH, Shub MD. Upper gastrointestinal endoscopy in infants: diagnostic usefulness and safety. Pediatrics 1984;74:828-31. 6. A1-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989;35:79-81. VOLUME 42, NO. 6, 1995